Patient Medical Homes (PMH) and Primary Care Networks (PCN)

The GPSC is working toward creating an integrated system of care that enables access to quality primary health care that effectively meets the needs of patients and populations in BC.

Why doctors should get involved

GPs have told us that they need help with:

  • Dealing with the administrative burden.
  • Caring for complex patients.
  • Maximizing a team.

Value proposition
We are freeing you up to do the work you love to do, and
for what brought you into the medical profession in the first place.

This work closely links family doctors to networks of care, including team-based support and specialty services at the practice level and in the community. With this clearer path to care, doctors can get better support to meet the growing needs and complexities of their patients. Patients can more easily move between their doctor’s offices and other health care providers to get quality care.

The health system is under strain on a number of fronts:

  • GPs are under stress and the threat of burnout is real.
  • Many patients can’t find a family doctor.
  • The system is difficult to navigate for patients and doctors.

Given the strains, change is inevitable. The GPSC is ensuring that family physicians remain central decision makers throughout the process and that divisions of family practice play a key role in the evolution of primary care in their communities.

Patient medical homes

Patient medical homes (PMH)

The patient medical home (PMH) is a family practice supported to operate at its full potential. The core of the model is longitudinal care, with the family practice at the centre of primary care. The PMH contains key attributes of what an ideal practice can deliver and how it can best be supported, including through team-based care. The PMH model is being implemented and tested around the world, which has given us the chance to learn from what other people have done. The 12 attributes of a patient medical home in BC are based on College of Family Physicians of Canada’s framework and pillars. The GPSC has adapted the PMH model to recognize the strong networking and partnership work that has already been done through the divisions of family practice, Health Authorities and community partners, as well as the collaborative framework of GPSC that is unique to BC.

Primary Care Networks

A primary care network (PCN) is a clinical network of service providers within a geographical area, with patient medical homes as the foundation, who work together to provide all the primary care services a population requires.

Guided by eight core attributes, PCNs enable family doctors and other primary care providers to enhance patient care with the support of teams of allied health professionals. In a team based model of care, everyone can work to their strengths and support each other, while ensuring patients get the best care.

A PCN is governed and supported by a partnership between the local division of family practice and health authority, supported by community partners, through the Collaborative Services Committee (CSC) (or PCN Steering Committee). In this partnership, GPs are integral in planning and influencing how local PCNs are designed to better support patients.

Physician leadership and division participation is essential to establishing PMHs and PCNs as the foundation of an integrated system of care.

PCN Development Process

  • When CSC partners are ready to move forward and formally engage in designing a local PCN or PCNs for their local community (or communities), they complete an Expression of Interest (EOI) template, indicating their readiness to participate. 
  • Once the EOI is reviewed and approved the CSC is provided with $150K change management funding as well as other supports to complete a Service Plan that meets their local needs.
  • The CSC is encouraged to focus their first phase of service planning on ensuring patients who do not have a primary care provider are attached to one. Once the attachment gap is narrowed, the focus is on redesigning local services and adding resources to optimize the team-based care approach.
  • Following approval of the Service Plan, CSCs are provided with funding to begin implementation.

Communities Underway

Across the province, CSCs are exploring opportunities to establish and support Primary Care Networks, building on other successful local initiatives.

Currently, 11 communities are engaged in planning services for local PCNs. The first wave of communities, soon to move into implementing their plans, are:

  • Burnaby
  • Comox Valley
  • Prince George
  • Richmond
  • South Okanagan Similkameen.
The next wave of communities are:
  • Fraser Northwest
  • Kootenay Boundary
  • Pacific Northwest (Smithers);
  • Ridge Meadows
  • South Island
  • Vancouver.

In the coming months, other CSCs will submit Expressions of Interest to begin work on PCNs in their communities. GPs are encouraged to contact their local division to participate in planning and designing services for patients in their community.

More information, including the EOI and Service Plan templates, is available by emailing gpsc@doctorsofbc.ca.

Proven model of care

There’s strong evidence that a system based on robust primary care is better for the patients, better for the physicians and other providers, and saves the system money.

Read more:

Ties to existing work

The groundwork has already been laid by doctors, divisions of family practice, and partners – as they have explored new and better ways to work together and create more unity between providers and the efforts of health authorities to streamline services. Now, with patient medical homes and primary care networks as central to an integrated system, there is an opportunity to bring it all together.